Of all the heavyweight problems burdening the NHS, mental health may be the most cumbersome.
The Department of Health’s website gives some indication of the challenge faced by the UK’s healthcare system:
At any one time around one adult in six is experiencing symptoms of mental illness and one in four will experience mental illness during their lifetime. Mental illness is the largest single cause of disability in our society and costs the English economy at least £77 billion a year.
And the burden may be growing; the number of antidepressants prescribed nearly doubled over the last ten years while at the same time previously controversial behavioural disorders like attention-deficit hyperactivity disorder (ADHD) became fully legitimate diagnoses, sending an increasing number of people to the doctor’s surgery.
With the NHS under great strain and the UK’s collective mental health apparently worsening, perhaps now is a good time to re-examine our approach to the mental and behavioural problems that so many of us encounter during our lives.
One of our society’s central assumptions is that mental health issues should be primarily a medical concern. However, in the 1960s a school of thought rose to counter this view: the “antipsychiatry” movement spearheaded, somewhat ironically, by two psychiatrists: R.D. Laing and Thomas Szasz.
There are profound differences between the writings of these two men but they share the idea that mental illnesses are not illnesses in the traditional, medical sense. Our treating them as such contributes to a medicalisation of society wherein abhorrent behaviours or mental states are pathologised by the pseudo-scientific rationale of modern psychiatry. Ultimately, they say, this attitude is unhelpful to the very people it seeks to treat - people with mental health problems.
So, is the current medical approach to mental health the right one to take? Our health editors, James Brooks and Lorna Powell argue it out.
James Brooks: Let me just say, before I try to win you over to my point of view, that when I say that mental health problems are fundamentally not medical problems I don’t mean to trivialise the suffering of the millions of people classified as having any one of these disorders. That’s important and I don’t want it to be forgotten in the ensuing debate.
But here’s the thing; medicine cannot cope with having the healing of all human suffering as its remit. Doctors study the human body and therefore their expertise lies in treating diseases and injuries and none of the conditions that fall under the banner of psychiatry really fit those descriptions.
Indeed the term “mental illness” is primarily a metaphorical one: how can the immaterial mind ever be ill? No, these disorders are better understood in a psycho-social context: they are “problems in living”, to borrow Tom Szasz’s phrase (and this phrase shouldn’t be taken as trivialising such serious problems).
That the medical establishment should monopolise dealing with them is as unjustified as it is unhelpful.
Lorna Powell: Doctors are experts in the human body but their job description goes way beyond just treating diseases and injuries. Modern medical training is designed to ensure doctors understand the need to treat a person and address their thoughts and feelings as well as physical ailments. Psychiatric conditions fall squarely into their remit.
Although the mind isn’t a lump of flesh it can still be unwell. Our psychological state is dictated, like any other part of the body, by the function of cells and tissues and chemicals. Yes, day to day “problems in living” influence our mental wellbeing but mental health illness still has a physical component. Just like any other system in our bodies the pathways can jar and normal function can go awry, producing a real deviation from normal mental state in the absence of any attendant social cause.
The easiest way to demonstrate this is through the countless research papers which compare neurochemical levels between control groups and people with psychiatric illnesses. And guess what: they’re not the same. For example, decades of studies have shown that schizophrenics have increased levels of dopamine in the brain (Abi-Dargham, A. et al, see references below).
JB: So thanks to five years in medical school, doctors are experts of the entire human condition and they can somehow address the ill-defined “thoughts and feelings” of their patients? This is doctors as the high priests of society, the epitome of medicalisation.
Fine, but then you go on to say that mental illness is in fact somatic. So these are genuine diseases anyway?
Schizophrenia is a strange choice to prove your point. The quest for a physical cause for this compound of disorders has been a long, fruitless crusade for medicine. Explanations have gone from over-excitation of the frontal lobes (cured by lobotomy, won the Nobel Prize in 1949) to today’s dopamine hypothesis. Here, excess dopamine could in fact be the result of some other process, possibly a reaction to the environment; some researchers suggest early life abuse as a risk factor (Read, J. et al).
I’m sceptical, but say the dopamine hypothesis were correct - then, yes, if they so wished, schizophrenics could be treated by neurologists. But their brains would be treated, not their minds.
Until the day when a doctor can diagnose schizophrenia by examining a brain scan – as currently occurs in Alzheimer’s – legitimate treatment by the medical establishment is impossible.
LP: We need to distinguish thoughts and feelings we have as conscious human beings from thought processes as symptoms of mental illness. The two are very different. Doctors don’t aim to “cure” patients’ thoughts and feelings. An appreciation of the way they interact with our health is fundamental to good practice but we all have unique outlooks, perspectives and beliefs and it is not necessary or ethical for doctors to try to alter these in the process of treating illness.
However, in mental health conditions thought processes and the feelings they produce are themselves the symptoms of the problem. In the same way liver disease can be recognised outwardly by jaundice, patients with schizophrenia display symptoms of paranoia or delusional beliefs. Although both are products of the mind they are still diagnostic flags for the condition.
The argument that disorders must be either of the brain or the mind is too simplistic as the two are so intertwined. Take your example of Alzheimer’s. Yes, a scan can sometimes pick up structural signs of brain disease that point towards the diagnosis but thousands of patients will have normal scans. The absence of physical proof doesn’t mean they don’t have the condition.
Degeneration of brain tissue is the cause of Alzheimer’s disease but many patients experience altered thoughts and feelings which are very much in the mind of the patient. Increased aggression, mood swings and depression are all recognised symptoms of the condition.
JB: The thing is you can’t distinguish mental states as symptoms of brain disorders from mental states as products of the ‘normal’ brain (no such thing, of course). What’s more, when it comes to psychiatric conditions, the underlying brain disorders haven’t been defined. So these are symptoms of diseases that may not even exist!
Functionally, psychiatry takes mental states that individuals find abhorrent and behaviours that society disparages and labels them as illnesses. (With regard to the latter, psychiatry has a particularly embarrassing track record; the World Health Organization didn’t fully withdraw its classification of homosexuality as a mental disorder until 1990.)
Yes, there are people who are wired a bit differently from the majority and, yes, those people may experience different and occasionally highly problematic mental states as a result but, I say again, medicine can only treat living tissue directly. It cannot treat the mind.
And anyway, such “neurodivergent” individuals are in the minority of people who go to their doctor for help with mental illness. The majority have depression or anxiety. These are mental states that are mostly normal – although frequently debilitating – adaptive reactions to environments or situations.
“Getting better” here is meaningless. If people wish to overcome depression or anxiety they must confront the situation that caused such reactions to occur; they need to assume responsibility and perhaps make radical changes in their lives.
Labelling these mental states as diseases to be treated provokes the opposite response; it victimises the “sufferer” and discourages active engagement with the problematic predicament.
LP: It is true that depression rates have soared in recent years and this, to some extent, is a result of over-diagnosis.
Some gastroenterologists are keen to label simple abdominal discomfort with terms such as “irritable bowel syndrome” where others feel there is no need to diagnose a normal variant in health. In the same way, many GPs and psychiatrists favour a diagnosis of depression where symptoms of low mood are perhaps more related to social situation and personal outlook than psychiatric illness.
It might be that some people who are wrongly diagnosed are able to take responsibility and make changes in their lives but for those with real psychiatric conditions this simply isn’t possible. The medicalisation of low mood is a phenomenon recognised by doctors all over the country but that doesn’t mean some patients don’t have depression as a true, organic mental condition.
Research into anti-depressant drugs supports this statement. A 2010 study (Fournier, J.C. et al) looked at the results of thirty years’ worth of research into the efficacy of selective serotonin reuptake inhibitors (the most commonly prescribed anti-depressant). The review found that the drugs do relieve severe depressive symptoms.
People with psychiatric conditions, however they are classified or diagnosed, have difficulties they need assistance with and the medical community is best equipped to help them. Its appreciation of the need for solid, evidence based practice is vital to the protection and treatment of some of the most vulnerable members of society.
JB: But your “real psychiatric conditions” remain undefined. It is therefore impossible to separate people with an “organic mental condition” from those without. (Why would we want to do this anyway? Psychological and behavioural problems are real whether they’re somatic or not.)
To say that those people arbitrarily tagged with having an “organic mental condition” are incapable of taking any responsibility is just a rationalisation of the paternalistic, coercive nature of psychiatry.
Your talismanic evocation of evidence based practice so soon after referencing a study showing that antidepressants are no better than placebo for people with mild to moderate depression (the majority of patients) is similarly perplexing.
And anyway people have been taking all kinds of drugs to ameliorate depression throughout history (Freud, famously, favoured cocaine). The fact that today we only have access to these substances via physicians doesn’t legitimise the disease model of mental illness or mean that the medics are otherwise best equipped to help with such problems.
Unfortunately, we’ve run out of space. I’m frustrated that I didn’t get the chance to outline how I think society should organise to help people encountering mental or behavioural problems. So thank you, Lorna, for not assuming that my misgivings about the medical approach mean that I think that nothing should be done or that such people should just “pull themselves together”.
We also agree on how serious and debilitating mental illness can be. Again, I’d like to thank you for your understanding that I’m not arguing that these problems aren’t real.
As our exchanges show, the debate over society’s approach to mental health is a complex one. But that doesn’t mean we should avoid it and leave our assumptions unchallenged. I’m sure you’ll join me when I say that it would be a positive development if this kind of debate gained wider public exposure.
Images: Phrenology model by Mark Strozier (Flickr); James and Lorna by Beki Hill (all rights reserved); Thomas Szasz by Zsolt Bugarszki (Flickr); Prozac by Tom Varco (Wikimedia Commons)
Abi-Dargham A, Gil R, Krystal J, Baldwin RM, Seibyl JP, Bowers M, van Dyck CH, Charney DS, Innis RB, & Laruelle M (1998). Increased striatal dopamine transmission in schizophrenia: confirmation in a second cohort. The American journal of psychiatry, 155 (6), 761-7 PMID: 9619147
Read, J., Os, J., Morrison, A., & Ross, C. (2005). Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications Acta Psychiatrica Scandinavica, 112 (5), 330-350 DOI: 10.1111/j.1600-0447.2005.00634.x
Fournier, J., DeRubeis, R., Hollon, S., Dimidjian, S., Amsterdam, J., Shelton, R., & Fawcett, J. (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis JAMA: The Journal of the American Medical Association, 303 (1), 47-53 DOI: 10.1001/jama.2009.1943
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